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Clinical Biomechanics 23 (2008) 10261037

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Patellofemoral compressive force and stress during the forward

and side lunges with and without a stride
Rafael F. Escamilla a,*, Naiquan Zheng b, Toran D. MacLeod a,h, W. Brent Edwards c,
Alan Hreljac d, Glenn S. Fleisig e, Kevin E. Wilk f, Claude T. Moorman III g,
Rodney Imamura d
b

a
Department of Physical Therapy, California State University, 6000 J Street Sacramento, CA 95819-6020, USA
The Center for Biomedical Engineering, Department of Mechanical Engineering and Engineering Science, University of North Carolina, Charlotte, NC, USA
c
Department of Kinesiology, Iowa State University, Ames, IA, USA
d
Kinesiology and Health Science Department, California State University, Sacramento, CA 95819-6020, USA
e
American Sports Medicine Institute, Birmingham, AL, USA
f
Champion Sports Medicine, Birmingham, AL, USA
g
Duke University Medical Center, Durham, NC, USA
h
Department of Physical Therapy, Center for Biomedical Engineering Research, University of Delaware, Newark, DE, USA

Received 31 July 2007; accepted 2 May 2008

Abstract
Background. Although weight bearing lunge exercises are frequently employed during patellofemoral rehabilitation, patellofemoral
compressive force and stress are currently unknown for these exercises.
Methods. Eighteen subjects used their 12 repetition maximum weight while performing forward and side lunges with and without a
stride. EMG, force platform, and kinematic variables were input into a biomechanical model, and patellofemoral compressive force and
stress were calculated as a function of knee angle.
Findings. Patellofemoral force and stress progressively increased as knee exion increased and progressively decreased as knee exion
decreased. Patellofemoral force and stress were greater in the side lunge compared to the forward lunge between 80 and 90 knee angles,
and greater with a stride compared to without a stride between 10 and 50 knee angles. There were no signicant interactions between
lunge variations and stride variations.
Interpretation. A more functional knee exion range between 0 and 50 may be appropriate during the early phases of patellofemoral
rehabilitation due to lower patellofemoral compressive force and stress during this range compared to higher knee angles between 60 and
90. Moreover, when the goal is to minimize patellofemoral compressive force and stress, it may be prudent to employ forward and side
lunges without a stride compared to with a stride, especially at lower knee angles between 0 and 50. Understanding dierences in patellofemoral compressive force and stress among lunge variations may help clinicians prescribe safer and more eective exercise interventions.
2008 Published by Elsevier Ltd.
Keywords: Knee pain; Knee kinetics; Knee biomechanics; Patellofemoral rehabilitation

1. Introduction
Patellofemoral rehabilitation results in millions of dollars
(USA) in medical cost each year, and employing exercise
*

Corresponding author.
E-mail address: rescamil@csus.edu (R.F. Escamilla).

0268-0033/$ - see front matter 2008 Published by Elsevier Ltd.

doi:10.1016/j.clinbiomech.2008.05.002

therapy during patellofemoral rehabilitation has demonstrated benecial, positive changes in cost eectiveness, pain
severity, and functional disability (van Linschoten et al.,
2006). Moreover, the quality of patellofemoral rehabilitation is paramount in determining the health and well being
of the patient, and a faster return to function (van
Linschoten et al., 2006). Consequently, judicious thought

R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

should be given in choosing patellofemoral rehabilitation

exercises.
Patellofemoral pain syndrome (PFPS), otherwise known
as anterior knee pain, is the most common cause of knee
pain in the outpatient setting, and accounts for 2530%
of all knee pathologies treated (Devereaux and Lachmann,
1984; Dixit et al., 2007; Fredericson and Yoon, 2006).
PFPS primarily aects younger (typically the 1840 age
range) active individuals, both athletes and non-athletes
(Dixit et al., 2007; Fredericson and Yoon, 2006; LaBella,
2004) and both males and females (Dehaven and Lintner,
1986), although older individuals can also be aected.
Because the etiology of PFPS is poorly understood and
multi-faceted, it remains one of the most dicult clinical
challenges in rehabilitative medicine (Wilk et al., 1998).
Although patellofemoral rehabilitation after injury can be
a long and arduous process, the use of appropriate exercises can improve this process by decreasing rehabilitation
time and improving function (Boling et al., 2006; Heintjes
et al., 2003; Natri et al., 1998; Witvrouw et al., 2004; Witvrouw et al., 2000).
Weight bearing exercises are frequently employed during
patellofemoral rehabilitation, and are specic to many functional activities such as walking, running, and jumping (Boling et al., 2006; Heintjes et al., 2003; Natri et al., 1998;
Witvrouw et al., 2004; Witvrouw et al., 2000). The use of
weight bearing exercises have been shown to be eective,
both in short and long term outcomes, in decreasing anterior
knee pain and enhancing functional performance (Boling
et al., 2006; Heintjes et al., 2003; Natri et al., 1998; Witvrouw et al., 2004; Witvrouw et al., 2000). Clinicians use these
types of exercises to minimize anterior knee pain and muscle
loss, strengthen hip and thigh musculature, enhance balance
and stability, and minimize the risk of future injuries and
associated costs of health care (van Linschoten et al.,
2006). Understanding how patellofemoral compressive
force and stress (force per unit patella contact area) vary
among weight bearing exercises allows physical therapists,
physicians, and trainers to prescribe safer and more eective
knee rehabilitation treatment to patients recovering from
knee injury or surgery. For example, if an exercise generates
greater patellofemoral compressive force and stress between
60 and 90 knee exion compared to 030 knee exion, the
030 knee exion range can be initiated at an earlier stage in
patellofemoral rehabilitation, while the 6090 knee exion
range can be initiated at a later stage in the rehabilitation
process. There may also be dierences in patellofemoral
compressive force and stress between dierent exercises over
a specic knee exion range.
Lunges are common weight bearing exercises used by
athletes and other individuals with healthy knees to train
the hip and thigh musculature. Therapists and trainers also
use lunges and similar weight bearing exercises during
patellofemoral rehabilitation for PFPS patients to allow
them to recover faster and return to function earlier (Boling et al., 2006; Heintjes et al., 2003; Natri et al., 1998;
Witvrouw et al., 2004; Witvrouw et al., 2000). Lunges

1027

can be done with varying techniques, such as forward or

side lunges, as well as lunging with a stride (striding forward or sideways with one leg and returning back to
upright position with feet together), or lunging without a
stride (keeping both feet stationary throughout the forward
or side lunge movements). However, patellofemoral compressive force and stress generated while performing forward and side lunges with and without a stride is
currently unknown.
Patellofemoral compressive force, which can elevate
subchondral bone stress (Besier et al., 2005), is a plausible
cause of pain in individuals with PFPS. Patellofemoral
stress can result in cartilage degeneration and a decrease
in the ability of the cartilage to distribute patellofemoral
compressive force (Besier et al., 2005). Therefore, it is
important for clinicians to understanding the magnitudes
of patellofemoral compressive force and stress generated
during dierent weight bearing rehabilitation exercises.
The purpose of this study was to compare patellofemoral
compressive force and stress between forward and side
lunges with and without a stride. It was hypothesized that
patellofemoral compressive force and stress would increase
as knee exion increased, would be greater with a stride
compared to without a stride, and would be greater in
the forward lunge compared to the side lunge.
2. Methods
2.1. Subjects
Eighteen healthy individuals (9 males and 9 females)
without a history of patellofemoral pathology participated
with an average(SD) age, mass, and height of 29(7) y,
77(9) kg, and 177(6) cm, respectively, for males, and 25(2)
y, 60(4) kg and 164(6) cm, respectively, for females. In
addition, all subjects were required to be able to perform
all exercises pain free and with proper form and technique
for 12 consecutive repetitions using their 12 repetition maximum (12 RM) weight.
To control the electromyographic (EMG) signal quality,
the current study was limited to males and females that had
average or below average body fat, which was assessed by
Baseline skinfold calipers (Model 68900, Country Technology, Inc., Gays Mill, WI, USA) and appropriate regression
equations and body fat standards set by the American College of Sports Medicine. Average (SD) body fat was 12(4)%
for males and 18(1)% for females. All subjects provided
written informed consent in accordance with the Institutional Review Board at California State University, Sacramento, USA, which approved the research conducted and
informed consent form.
2.2. Exercise descriptions
2.2.1. Forward lunge
Each subject performed the forward lunge (Fig. 1a) both
with and without stride. The starting and ending positions

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R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

Fig. 1. (a) Forward lunge; (b) side lunge.

for the forward lunge with a stride were the same, which
involved standing upright with both feet together. From
the starting position for the forward lunge with a stride,
the subject held a dumbbell weight in each hand and lunged
forward with the right leg toward a force platform at
ground level. The dumbbell weight used during the forward
lunge with stride was normalized by each subjects 12 RM
weight, and this same weight was used during the forward
lunge without stride. The mean (SD) mass of both dumb-

bells during the forward lunge was 49(11) kg for males

and 32(8) kg for females. At right foot contact the right
knee slowly exed until maximum right knee exion of
90100 was obtained as the left knee made contact with
the ground. From this ending position the subject immediately pushed backward o the force platform and returned
to the starting position. A metronome was used to ensure
that the knee exed and extended at approximately 45/s.
Each subject was instructed to use as long a stride length

R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

as was comfortable. A tester ensured that the stride was

long enough so that at the lowest position of the lunge
the stride knee was maintained over the stride foot without
translating forward beyond the toes. The average (SD)
stride length (measured from left toe to right heel) during
the forward lunge of 89(4) cm for males and 79(6) cm for
females. During the forward lunge, a longer stride length
is commonly preferred by individuals compared to a
shorter stride length to ensure that the stride knee does
not progress beyond the toes at the lowest position of the
forward lunge (Fig. 1a). The forward lunge without stride
was performed the same as the forward lunge with stride
with the exception that both feet remained stationary
throughout each repetition during the forward lunge without stride. That is, from the lowest position of the forward
lunge shown in Fig. 1a, the subject simply fully extended
both knees, and then exed both knees back to return to
the lowest position of the forward lunge shown in Fig. 1a.
2.2.2. Side lunge
Each subject performed the side lunge (Fig. 1b) both
with and without a stride. The starting and ending positions for the side lunge with a stride were both the same,
which involved standing upright with both feet together.
From the starting position for the side lunge with a stride,
the subject held a single dumbbell weight down between the
legs and lunged sideways with the left knee remaining fully
extended and the right leg moving toward a force platform
at ground level. The dumbbell weight used during the side
lunge with stride was normalized by each subjects 12 RM
weight, and this same weight was used during the side lunge
without stride. On the average (SD), the dumbbell mass
used during the side lunge was 34(9) kg for males and
20(5) kg for females. At right foot contact the right foot
was turned out approximately 3045 relative to the left
foot (subjects preference) and the right knee exed slowly
at approximately 45/s until the right knee exed approximately 90100 (Fig. 1b) as the left knee remained fully
extended. From this ending position the subject then
pushed backward o the force platform and returned to
the starting position. A metronome was used to ensure that
the knee exed and extended at approximately 45/s. Each
subject was instructed to use as long a stride length as was
comfortable. A tester ensured that the stride was long
enough so that at the lowest position of the lunge the stride
knee was maintained over the stride foot without translating forward beyond the toes. The average (SD) stride
length (measured from inside of left heel to inside of right
heel) during the side lunge was 94(5) cm for males and
83(3) cm for females. Using a longer stride length compared to a shorter stride length during the side lunge is
commonly preferred by individuals as it allows the left knee
to remain straight and the right knee to ex approximately
90100 and remain over the foot. The side lunge without
stride was performed the same as the side lunge with stride
with the exception that both feet remained stationary
throughout each repetition during the side lunge without

1029

stride. That is, from the lowest position of the side lunge
shown in Fig. 1b, the subject simply fully extended the right
knee (left knee was already extended), and then returned
back to the lowest position of the side lunge by exing
the right knee.
2.3. Data collection
Each subject came in for a pre-test one week prior to the
testing session. At that time the experimental protocol was
reviewed and the subject was given the opportunity to ask
questions. In addition, each subjects 12 RM was determined for the forward and side lunges by utilizing the most
weight they could lift for 12 consecutive repetitions. Moreover, each subjects stride length (as previously dened)
was measured for the forward and side lunges.
Blue Sensor (Ambu Inc., Linthicum, MD, USA) disposable surface electrodes (type M-00-S) were used to collect
EMG data. These oval shaped electrodes (22 mm wide and
30 mm long) were placed in a bipolar electrode conguration
along the longitudinal axis of muscle, with a center-to-center
distance of approximately 3 cm between electrodes. Prior to
positioning the electrodes over each muscle, the skin was prepared by shaving, abrading, and cleaning with isopropyl
alcohol wipes to reduce skin impedance. As previously
described, (Basmajian and Blumenstein, 1980) electrode
pairs were then placed on the subjects right side for the following muscles: (1) rectus femoris; (2) vastus lateralis; (3)
vastus medialis; (4) medial hamstrings (semitendinosis and
semitendinosus); (5) lateral hamstrings (biceps femoris);
and (6) gastrocnemius.
EMG data were collected at 960 Hz using a Noraxon
Myosystem EMG unit (Noraxon USA, Inc., Scottsdale,
AZ, USA). The amplier bandwidth frequency was 10
500 Hz, the input impedance of the amplier was
20,000 kX, and the common-mode rejection ratio was
130 Db. EMG signals were processed through an analog to
digital (A/D) converter by a 16 bit A/D board.
Spheres (3.8 cm in diameter) covered with 3 M reective
tape were attached to adhesives and positioned over the following bony landmarks: medial and lateral malleoli of the
right foot; upper edges of the medial and lateral tibial plateaus of the right knee; posterosuperior greater trochanters
of the left and right femurs; lateral acromion of the right
shoulder; and third metatarsal head of the right foot.
A six camera Peak Performance motion analysis system
(Vicon-Peak Performance Technologies, Inc., Englewood,
CO, USA) was used to collect 60 Hz video data. Each subject performed each lunge variation with their right foot on
an AMTI force platform (Model OR6-6-2000, Advanced
Mechanical Technologies, Inc.) and their left foot on the
ground (Fig. 1a and b), with force platform data collected
at 960 Hz. Once the electrodes were positioned, the subject
warmed up and practiced the exercises as needed, and data
collection commenced. Video, EMG, and force platform
data were electronically synchronized and collected as each
subject performed in a randomized manner one set of three
TM

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R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

continuous repetitions (trials) during the forward lunge

with stride, forward lunge without stride, side lunge with
stride, and side lunge without stride.
Subsequent to completing all exercise variations, EMG
data were collected during maximum voluntary isometric
contractions (MVIC) to normalize the EMG data collected
during each lunge variation. The MVIC for the rectus femoris, vastus lateralis, and vastus medialis were collected in a
seated position at 90 knee and hip exion with a maximum
eort knee extension. The MVIC for the lateral and medial
hamstrings were collected in a seated position at 90 knee
and hip exion with a maximum eort knee exion. MVIC
for the gastrocnemius was collected during a maximum
eort standing one leg toe raise with the ankle positioned
approximately halfway between neutral and full plantar exion. Two 5 s trials were randomly collected for each MVIC.
2.4. Data reduction
Video images for each reective marker were tracked
and digitized in three-dimensional space with Peak Performance software, utilizing the direct linear transformation
calibration method (Shapiro, 1978). Testing of the accuracy of the calibration system resulted in reective balls
that could be located in three-dimensional space with an
error less than 0.7 cm. The raw position data were
smoothed with a double-pass fourth order Butterworth
low-pass lter with a cut-o frequency of 6 Hz (Escamilla
et al., 1998). Joint angles, linear and angular velocities,
and linear and angular accelerations were calculated in a
two-dimensional sagittal plane of the knee utilizing appropriate kinematic equations (Escamilla et al., 1998).
Raw EMG signals were full-waved rectied and
smoothed with a 10 ms moving average window (linear
enveloped) throughout the knee range of motion for each
repetition. These EMG data were then normalized for each
muscle and expressed as a percentage of each subjects
highest corresponding MVIC trial. The MVIC trials were
calculated using the highest EMG signal over a 1 s time
interval throughout the 5 s MVIC. Normalized EMG data
for the three repetitions (trials) were then averaged at corresponding knee angles between 0 and 90, and were used
in the biomechanical model described below.
2.5. Biomechanical model
As previously described (Escamilla et al., 1998; Zheng
et al., 1998), a biomechanical model of the knee was used
to continuously calculate patellofemoral forces throughout
a 90 knee range of motion during the knee exing (090)
and knee extending (900) phases of the lunge exercises.
Resultant force and torque equilibrium equations were calculated using inverse dynamics and the biomechanical knee
model (Escamilla et al., 1998; Zheng et al., 1998). Moment
arms of muscle forces and angles of the line of action for
muscles were represented as polynomial functions of the
knee exion angle using data from Herzog and Read (1993).

Quadriceps, hamstrings, and gastrocnemius muscle

forces were calculated as previously described (Escamilla
et al., 1998; Zheng et al., 1998). Because the accuracy of
calculating muscle forces depends on accurate calculations
of a muscles physiological cross-sectional area (PCSA),
maximum voluntary contraction force per unit PCSA,
and the EMG-force relationship, resultant force and torque equilibrium equations may not be satised. Therefore,
each muscle force Fm(i) was modied by the following equation: Fm(i) = ciklikviAirm(i)[EMGi/MVICi], where Ai was
PCSA of the ith muscle, rm(i) was MVIC force per unit
PCSA of the ith muscle, EMGi and MVICi were EMG
window averages of the ith muscle EMG during exercise
and MVIC trials, ci was a weight factor (explained below)
adjusted in a computer optimization program to minimize
the dierence between the resultant torque from the inverse
dynamics (Tres) and the resultant torque calculation from
the biomechanical model (Tmi), kli represented each muscles forcelength relationship as function of hip and knee
angles (based on muscle length, ber length, sarcomere
length, pennation angle, and cross-sectional area) (Wickiewicz et al., 1983), and kvi represented each muscles
forcevelocity relationship based on a Hill-type model for
eccentric and concentric muscle actions using the following
equations from Zajac (1989)) and Epstein and Herzog
(1998):
k v b  a=F 0 v=b v
concentric
k v C  C  1b a=F 0 v=b  v
eccentric
with F0 representing isometric muscle force, v = velocity,
a = 0.32 F0, b = 3.2 l0/sec, and C = 1.8. Muscle force from
eccentric contractions was scaled up by 1.8 times the isometric muscle force F0. Forces generated by the knee exors and extensors at MVIC were assumed to be linearly
proportional to their physiological cross-sectional area.
Muscle force per unit physiological cross-sectional area at
MVIC was 35 Ncm2 for the knee exors and 40 Ncm2
for the quadriceps (Cholewicki et al., 1995; Narici et al.,
1992; Narici et al., 1988; Wickiewicz et al., 1984).
The objective function used to determine each ith muscles coecient ci was as follows:
min

f ci

nm
X
i1

1  ci kT res 

nm
X

T mi ;

i1

subject to clow 6 ci6chigh, where clow and chigh were lower

and upper limits for ci, and k was a constant. The weight
factor c was to adjust the nal muscle force calculation.
The bounds on c were set between 0.5 and 1.5. The torques predicted by the EMG driven model matched well
(<2%) with the torques generated from the inverse dynamics. The assumptions associated with this model are (1) the
torque from cruciate ligament forces were ignored (2) other
forces and torques out of the sagittal plane were ignored.
Patellofemoral force was a function of patellar tendon
force and quadriceps tendon force. Patellar tendon force
was calculated by the quadriceps tendon force and the ratio

R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

of the patellar tendon force and the quadriceps tendon

force, as previously described (van Eijden et al., 1986;
van Eijden et al., 1987). The angles between the patellar
tendon, quadriceps tendon, and patellofemoral joint were
expressed as functions of knee angle (van Eijden et al.,
1986; van Eijden et al., 1987).
Patellofemoral stress, which was calculated every 10
between 0 and 90 knee angle, was expressed as the ratio
of patellofemoral force (calculated from the biomechanical
model described above) and patellar contact area (Escamilla et al., 1998; Zheng et al., 1998). Patellar contact areas
were determined at 10 intervals between 0 and 90 knee
angle. Contact areas from in vivo MRI data from Salsich
et al. (2003) (who used both male and female subjects with
healthy knees and had them perform weight bearing exercise using resistance, similar to the current study) were used
at 0 (146 mm2), 20 (184 mm2), 40 (290 mm2), and 60
(347 mm2) knee angles. These four contact area values
formed a near linear relationship as a function of knee
angle, resulting in a line of best t equation of
y = 3.55x + 135 (r = 0.98) with y = contact area and
x = knee angle. This line of best t equation was used to
determine contact areas at 10 knee angle (171 mm2), 30
knee angle (242 mm2), and 50 knee angle (313 mm2).
The contact areas at 40, 50, and 60 knee angles were
used to develop the line of best t equation
y = 2.81x + 176 (r = 0.99), which was used to determine
contact areas at 70 knee angle (373 mm2), 80 knee angle
(401 mm2), and 90 knee angle (429 mm2). Like the current
study, a near linear relationship between patellar contact
area and knee angles has been reported between 0 and
90 knee angles in several studies involving weight bearing
exercises (Besier et al., 2005; Cohen et al., 2001; Hinterwimmer et al., 2005; Patel et al., 2003; Salsich et al., 2003).
2.6. Data analysis
To determine signicant dierences in patellofemoral
forces between the two lunge variations (forward lunge
and side lunge) and two stride variations (with stride and
without stride), patellofemoral forces were statistically analyzed every 10 during the 090 knee exing phase and the
900 knee extending phase using a two factor (lunge variations and stride variations) repeated measure Analysis of
variance. Bonferroni t-tests were used to assess pairwise
comparisons. The level of signicance used was P < 0.01.
Because each patellofemoral stress value was derived by
dividing each patellofemoral force value by a constant for
each lunge variation and each stride variation, patellofemoral stress values between lunge and stride variations will
have the same P values as the corresponding patellofemoral force values in which they were derived.
3. Results
Patellofemoral force and stress progressively increased
as knee exion increased and progressively decreased as

1031

knee exion decreased (Figs. 27). Table 1 shows patellofemoral force values as a function of knee angle between forward and side lunges and between with a stride and
without a stride. From Table 1, between 80 and 90 knee
angles of the knee exing phase and at 90 knee angle of the
knee extending phase patellofemoral force and stress were
greater in the side lunge compared to the forward lunge.
Between 10 and 50 knee angles of the knee exing phase
and between 50 and 20 knee angles of the knee extending
phase patellofemoral force and stress were signicantly
greater with a stride compared to without a stride. There
were no signicant interactions between lunge variations
and stride variations.
4. Discussion
Both patellofemoral compressive force and stress can
result in the degeneration of patellofemoral cartilage and
anterior knee pain from subchondral bone, synovial plicae,
infrapatellar fat pad, retinacula, joint capsule, tendons and
ligaments (Biedert and Sanchis-Alfonso, 2002). Another
proposed mechanism of anterior knee pain is increased
patellar cartilage stress from patellofemoral compressive
force leading to subchondral bone stress (Biedert and Sanchis-Alfonso, 2002), and it has been demonstrated that the
subchondral bone plate is rich in pain receptors (Wojtys
et al., 1990). Therefore, understanding dierences in patellofemoral compressive force and stress among forward and
side lunge variations is helpful to the clinician when prescribing therapeutic exercises to individuals with PFPS.
Contrary to our original hypothesis, patellofemoral
compressive force and stress were greater while performing
the side lunge compared to the forward lunge, but only at
higher knee angles between 80 and 90. From these data it
can be concluded that loading the patellofemoral joint is
similar between forward and side lunges except at higher
knee angles, where patellofemoral loading was greater in
the side lunge.
As hypothesized, patellofemoral compressive force and
stress were greater with a stride compared to without a
stride, but only between 0 and 50 knee angles. Performing
forward and side lunges without a stride within a smaller
knee angle range (eg, 050) may be easier and safer to start
with earlier during patellofemoral rehabilitation when the
goal to minimize patellofemoral compressive force and
stress, while the performing forward and side lunges with
a stride may be more appropriate later during patellofemoral rehabilitation due to greater patellofemoral compressive force and stress compared to without a stride.
Patellofemoral compressive force and stress curves were
similar in shape to each other due to proportional increases
in patellofemoral compressive force and patellar contact
area with increased knee exion. One exception was with
knee angles between 80 and 90, which resulted in a
decrease in patellofemoral stress. This occurred because
although patellar contact area increased between 80 and
90, patellofemoral compressive force did not increase

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R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

Fig. 2. Mean (SD) patellofemoral compressive force between forward and side lunges with a stride.

Fig. 3. Mean (SD) patellofemoral stress between forward and side lunges with a stride.

proportionally, but instead began to plateau. This implies

that patellofemoral stress decreased during forward and
side lunges as maximum knee exion was approached.
These ndings are consistent with patellofemoral compressive force and stress data during the barbell squat from
Escamilla et al. (1998) and Salem and Powers (2001).
Escamilla et al. (1998) reported that patellofemoral compressive forces increases until 7580 knee exion, and then
began to level o and plateau or slightly decrease. Salem
and Powers (2001) reported no signicant dierences in
patellofemoral compressive force or stress at 75, 100,
and 110 knee exion. It can be concluded from these squat
data that injury risk to the patellofemoral joint may not
increase with knee angles between 75 and 110 due to similar magnitudes in patellofemoral stress during these knee
angles, with the benet of increased quadriceps, ham-

strings, and gastrocnemius activity when training at higher

knee angles (75110) compared to training at lower knee
angles (075) (Escamilla et al., 1998).
Another consideration during patellofemoral rehabilitation is what knee exion range of motion to employ while
performing lunge exercises. Because patellofemoral compressive force and stress both increased with increased knee
exion and decreased with decreased knee exion, a more
functional knee exion range between 0 and 50 may be
appropriate during the early phases of patellofemoral rehabilitation due to lower patellofemoral compressive force
and stress that is generated during this range of motion.
Higher knee angles between 60 and 90 may be more
appropriate later in the rehabilitation process due to higher
patellofemoral compressive force and stress that are generated during this range of motion. For example, during the

R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

1033

Fig. 4. Mean (SD) patellofemoral compressive force between forward and side lunges without a stride.

Fig. 5. Mean (SD) patellofemoral stress between forward and side lunges without a stride.

knee extending phase of the forward lunge, patellofemoral

compressive force ranged from 66 to 1176 N between 0
and 50 knee angle and from 1577 to 2191 N between 60
and 90 knee angle (Table 1), and patellofemoral stress ranged from 0.43 to 3.76 MPa between 0 and 50 knee angle
and from approximately 4.545.11 MPa between 60 and
90 knee angle. This same pattern of increased patellofemoral compressive force and stress with increased knee
exion has been reported during the barbell squat and leg
press (Escamilla et al., 1998; Escamilla et al., 2001; Salem
and Powers, 2001; Steinkamp et al., 1993; Wallace et al.,
2002). These authors reported that patellofemoral compressive force and stress progressively increased from 0
to approximately 90, peaked near 90, and then progressively decreasing from approximately 900. Computer
optimization techniques demonstrated similar results during a simulated squat (Cohen et al., 2003).

Peak patellofemoral force and stress magnitudes from

the current study are greater compared to weight bearing
functional exercises such as walking (Heino Brechter and
Powers, 2002) and going up and down stairs (Brechter
and Powers, 2002), but less than other weight bearing
activities, such as the squat and leg press (Escamilla
et al., 1998). Escamilla et al. (1998) reported peak patellofemoral force magnitudes between 4500 and 4700 N at 90
knee angle during the 12 RM squat and leg press using
healthy subjects, resulting in patellofemoral stress magnitudes between 11 and 12 MPa. These peak force and stress
magnitudes during the squat and leg press are approximately 60% greater compared to peak force and stress magnitudes in the current study, which also occurred at 90
knee angle. Peak patellofemoral force and stress in healthy
subjects during fast walking reportedly are approximately
900 N and 3.13 MPa, respectively (Heino Brechter and

1034

R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

Fig. 6. Mean (SD) patellofemoral compressive force between forward lunge with and without a stride.

Fig. 7. Mean (SD) patellofemoral compressive force between side lunge with and without a stride.

Powers, 2002), which are approximately 23 times lower

than the peak force and stress magnitudes in the current
study. However, peak patellofemoral force and stress magnitudes in healthy subjects going up and down stairs
reportedly are approximately 2500 N and 7 MPa, respectively (Heino Brechter and Powers, 2002), which are similar
to the peak force and stress magnitudes in the current
study.
Unlike healthy subjects, patients with patellofemoral
pathologies have demonstrated smaller patellar contact
areas and greater patellofemoral stress during some weight
bearing functional activities.(Brechter and Powers, 2002;
Heino Brechter and Powers, 2002). However, for both
healthy subjects and patients with patellofemoral pathologies it is currently unknown what patellofemoral force or
stress magnitudes, and over what time duration, can ultimately lead to patellofemoral pathology or exacerbate an

existing condition. There are many factors that may contribute to patellofemoral pathology, such as: (1) imbalance
or malalignment of the extensor mechanism, which can
lead to lateral patellar subluxation or tilt; (2) muscle weakness, such as weak quadriceps and hip external rotators; (3)
overuse or trauma; (4) muscle tightness, such as tight quadriceps, hamstrings, or iliotibial band; (5) lower extremity
malalignment, such as patella alta; genu valgum, femoral
neck anteversion, excessive Q angle; and excessive rearfoot
pronation. It can only be surmised that relatively large
patellofemoral force and stress magnitudes over time may
lead to or exacerbate patellofemoral pathology, especially
in individuals that exhibit some of the above factors and
are predisposed to patellofemoral problems. Clinicians
can use information regarding patellofemoral force and
stress magnitudes among dierent weight bearing exercises,
technique variations, and functional activities to more

R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

1035

Table 1
Mean (SD) patellofemoral force (N) values between lunge variations (forward lunge versus side lunge) and stride variations (with a stride versus without
a stride)
Knee angle for knee exing phase

0
10
20
30
40
50
60
70
80
90
Knee angle for knee extending phase
90
80
70
60
50
40
30
20
10
0
*

Exercise variations

Stride variations

Forward lunge

Side lunge

P-value

With stride

Without stride

P-value

69 62
159 143
207 152
356 190
628 236
1059 425
1524 550
1944 672
2161 657
2185 654

46 46
127 149
194 183
332 245
573 328
926 408
1533 579
2009 619
2493 702
2668 788

0.115
0.483
0.550
0.999
0.390
0.127
0.847
0.445
0.009*
<0.001*

74 76
220 181
301 198
459 247
732 314
1150 485
1683 629
2058 730
2344 742
2411 748

49 39
80 53
120 63
242 109
481 180
856 292
1378 443
1896 550
2267 645
2419 774

0.350
0.009*
0.002*
0.002*
<0.001*
0.003*
0.026
0.263
0.382
0.669

2191 662
2102 739
1937 786
1577 706
1176 525
780 344
504 240
312 180
168 119
66 46

2551 783
2239 743
1779 675
1363 561
999 447
680 339
445 252
268 169
160 111
66 82

<0.001*
0.181
0.482
0.271
0.211
0.206
0.250
0.170
0.841
0.999

2309 686
2146 776
1886 852
1579 772
1217 574
833 370
567 234
383 177
228 126
73 56

2400 788
2182 713
1846 621
1387 503
983 386
643 293
395 228
230 150
116 75
63 69

0.862
0.239
0.072
0.025
0.008*
0.006*
0.002*
0.009*
0.020
0.743

Signicant dierence (P < 0.01) between lunge variations or stride variations.

eectively make informed decisions regarding which exercise they choose to employ during patellofemoral
rehabilitation.
There are some limitations in the current study. Firstly,
MRI knee kinematic data have shown during the weight
bearing squat that the femur moves and rotates underneath
a relatively stationary patella, and if this femoral rotation is
excessive it may result in an increase in patellofemoral
stress on the contralateral patellar facets (Doucette and
Child, 1996; Li et al., 2004; Powers, 2003). This implies that
excessive medial femoral rotation may place more stress on
the lateral patellar facets, while excessive lateral femoral
rotation may place more stress on the medial patellar facets. Unfortunately, collecting MRI knee kinematic data
while performing the lunge is not currently possible due
to technology limitations, so it is unknown how much femoral rotation occurs during the lunge, how this rotation
varies among individuals (healthy and pathologic), and if
femoral rotation occurs in the lunge similar to how it
occurs in the squat.
Another limitation is the eect of Q-angle on patellofemoral compressive force and stress. From cadaveric data
during a simulated squat it was shown that an increased
Q-angle signicantly caused a lateral shift and medial tilt
and rotation of the patella, which may increase patellofemoral stress (Mizuno et al., 2001). It is currently not feasible to eectively measure lateral shift and medial tilt and
rotation of the patellar while performing the lunge. Moreover, increased medial femoral rotation, which also
increases Q-angle, is also dicult to measure accurately
while performing the lunge.

There are also limitations in the biomechanical model.

Firstly, muscle and patellofemoral forces were estimated
from modeling techniques and not measured directly,
which is currently not possible in vivo. Secondly, patellofemoral stress magnitudes were measured using patellar contact area values from MRI data from the literature and
were not measured directly. However, the contact areas
used from the literature were determined during loaded
weight bearing exercise in healthy male and female subjects, similar to the current study. Moreover, the near linear
and direct relationship between contact area and knee
angle has been shown to be similar among studies (Besier
et al., 2005; Cohen et al., 2001; Hinterwimmer et al.,
2005; Patel et al., 2003; Salsich et al., 2003). Thirdly, there
are limitations regarding the magnitude of patellofemoral
contact areas (and concomitant stress magnitudes), in
which the literature reports a wide array of values (Besier
et al., 2005; Cohen et al., 2001; Hinterwimmer et al.,
2005; Patel et al., 2003; Salsich et al., 2003). Dierences
in patellar contact area magnitudes and concomitant patellofemoral stress magnitudes among weight bearing studies
are due to many factors, such as sex, mass, measuring techniques, and loading magnitudes. Nevertheless, although
patellofemoral stress magnitudes during weight bearing
exercises or functional activities in the current study are
approximations only and not exact values, these varying
magnitudes may be helpful to clinicians in deciding interventions to employ during patellofemoral rehabilitation.
Finally, the current study was limited to healthy subjects
who were able to perform the lunge in the sagittal plane
of motion without transverse and frontal plane motions.

1036

R.F. Escamilla et al. / Clinical Biomechanics 23 (2008) 10261037

Future studies are needed during the lunge and other

weight bearing exercises to investigate the eects of transverse plane rotary motions and frontal plane valgus/varus
motions on patellofemoral force and stress magnitudes,
which may occur with individuals with patellofemoral
pathology.
5. Conclusions
Patellofemoral compressive force and stress magnitudes
were greater at higher knee angles and smaller at lower
knee angles, were greater during the side lunge compared
to the forward lunge between 80 and 90 knee angles,
and were greater with a stride compared to without a stride
between 10 and 50 knee angles. A more functional knee
exion range between 0 and 50 may be appropriate during the early phases of patellofemoral rehabilitation due to
lower patellofemoral compressive force and stress during
this range compared to higher knee angles between 60
and 90. Moreover, when the goal is to minimize patellofemoral compressive force and stress, it may be prudent to
employ forward and side lunges without a stride compared
to with a stride. Understanding dierences in patellofemoral compressive force and stress among lunge variations
help clinicians prescribe safer and more eective exercise
interventions.
Acknowledgements
The authors would like to thank Lisa Bonacci, Toni
Burnham, Juliann Busch, Kristen DAnna, Pete Eliopoulos, & Ryan Mowbray for all their assistance during data
collection and analyses.
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